ACCEPTANCE FORM - North Star Troubled Teen Treatment Center

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Acceptance Application

Please fill out our Acceptance application form below so we can review your child’s needs.

Page 1 of 5

Parent / Guardian Information

First Name*

Email address*

Last Name*

Phone Number*

Relationship*

Address*

City*

State*

Zip*

Patient Information

Patient First Name*

Date of Birth*

Patients Grade*

Patient Last Name*

Patient Height*

School Attending *

Patient Weight*

Assessment

Is the Patient Suicidal?

yes

Is there any verbal expressions of suicide?

yes

Is there any physical harm to self? (cutting, eating disorder, etc.)

yes

Any suicidal attempts?

yes

If the child went to the hospital for any of these, did the Dr. indicate that it was an actual suicide attempt or was it attention seeking behavior?

suicide attempt

attention seeking behavior

Is the patient violent with any other kids, siblings or property?

yes

If the answer to any of these questions is YES, please list the details.

Legal Standing

Has the patient been arrested?

yes

Is the patient on probation?

yes

Is there a court date?

If the answer to any of these questions is YES, please list the details.

Insurance Application

Does the patient have private insurance?

yes

Policy Holder / Insurance Information

Policy Holder Name*

Policy Holder Phone Number*

Insurance Provider Phone Number*

Policy Holder State*

Policy Holder Date of Birth*

Insurance ID Number*

Policy Holder employer*

Insurance Provider*

Insurance Group ID Number*

This field should be left blank

ACCEPTANCE FORM

INSURANCE VERIFICATION

APPLY FOR FINANCING

PAYMENT

REGISTRATION

Contact Info

Phone: 1-800-635-0165
Fax: 1-435-216-4008
Email: northstartreatmentcenter@gmail.com

Adress: 254 South State Street, Suite A
La Verkin, Utah